Long bone fractures, the fracture process and management

Question 1

What are long bones characterised by?

Answer 1

Diaphysis (shaft)
Metaphysis (around the growth plate)
Epiphysis (above the growth plate)

Question 2

When does primary bone healing occur?

Answer 2

With minimal fracture gap (e.g. hairline fractures, or when fractures are fixed with compression screws and plates)

Question 3

Outline the process of healing by secondary intention along with timeframes of when this would happen.

Answer 3

Haematoma and inflammation at the fracture gap (immediate)
Formation of granulation tissue, followed by soft callus (2-3 weeks)
Ossification and calcium mineralization forming hard callus (6-12 weeks)
Continuous remodelling over time

Question 4

What are the main requirements for fracture healing?

Answer 4

Good blood supply and a little tension/bending/movement

Question 5

What is soft callus and what cells form it?

Answer 5

Cartilage- chondroblasts

Question 6

What are the five basic fracture patterns?

Answer 6

Transverse; oblique; spiral; comminuted; segmented

Question 7

Name five factors which impair fracture healing.

Answer 7

Smoking; vascular disease; chronic ill health; malnutrition; excessive movement at fracture site

Question 8

In describing a fracture, what factors should be taken into account?

Answer 8

Location; type of fracture; degree of angulation; degree of displacement

Question 9

When might MRI or bone scan be used to detect fractures?

Answer 9

Occult fractures with clinical suspicion but no sign on X-ray; stress fractures

Question 10

What is a useful rule of thumb for whether an X-ray should be taken?

Answer 10

If the patient cannot bear weight on the affected part

Question 11

How should suspected fractures initially be assessed?

Answer 11

Closed/open?
Neurovascular status
Soft tissue damage?
Compartment syndrome?

Question 12

When might CT be used in fracture investigation?

Answer 12

Complex bones such as the vertebrae/pelvis

Question 13

Generally speaking, how should minimally displaced/angulated stable fractures be managed?

Answer 13

Splintage or immobilization, followed by rehab

Question 14

How should displaced or angulated fractures be managed?

Answer 14

Closed reduction (under anaesthetic) and cast application- may need surgical stabilisation

Question 15

When might ORIF be avoided in unstable extra-articular fractures, and what are the alternatives?

Answer 15

Patients with soft tissuu swelling, tenuous blood supply, where plate fixation may be prominent. Alternatives- IM nail with distant dissection, or external fixation (risk of infection/loosening)

Question 16

What might be the consequence of failing to reduce and internally fixate a displaced intra-articular fracture?

Answer 16

Post-traumatic osteoarthritis

Question 17

What antibiotics are given in the management of open fractures?

Answer 17

Flucloxacillin (Gram +ves)
Gentamicin (Gram -ves)
Metronidazole (anaerobes)

Question 18

How are open fractures managed surgically?

Answer 18

Early and thorough debridement; external or internal fixation; wound closure/skin graft

Question 19

What causes compartment syndrome?

Answer 19

Muscle/soft tissue swelling increases pressure within the compartment; causes venous congestion, backlog and ischaemia

Question 20

What does the absence of pulses in compartment syndrome indicate?

Answer 20

Diagnosis has been made too late

Question 21

What is the immediate surgical management of compartment syndrome?

Answer 21

Fasciectomy to relieve pressure; operative stabilization; wound closure/skin graft after 48 hours

Question 22

Which vessel is at risk from knee dislocation?

Answer 22

Popliteal artery

Question 23

What are the signs of reduced distal circulation?

Answer 23

reduced/absent pulses; cold to touch; pallor; delayed cap refill

Question 24

How is potential vascular injury assessed?

Answer 24

Angiography

Question 25

How might vascular damage be surgically repaired?

Answer 25

Vascular shunt; repair; stenting